Introduction

Hidradenitis suppurativa (HS), also known as acne inversa, is a chronic, inflammatory, recurrent disease of the hair follicle, primarily affecting apocrine gland-bearing areas. It primarily affects the gluteal, perineal, axillae, and inguinal regions, which are most commonly involved.¹ It presents with deep-seated, chronic nodules, sinus tracts, fistulae, and abscesses, which may result in pain, restricted mobility, functional impairment, and significant physical and psychosocial bur-den, thereby leading to a reduced quality of life.² In the literature, the prevalence of HS has been reported to range between 0.05 and 4.1%, with females being more commonly affected. Hidradenitis suppurativa has a multifactorial etiol-ogy and pathogenesis; consequently, its management is challenging.³ Management strategies for HS encompass both medical and surgical approaches. Medical treatment includes topical and systemic antibiotics, intralesional and systemic corticosteroids, hormonal therapy, and immuno-modulatory agents, while surgical options range from limit-ed lesion deroofing to radical excision of affected tissue.⁴ Surgical options for HS include incision and drainage for acute abscesses, deroofing of sinus tracts, limited or localized excision of diseased tissue, wide excision of affected areas, and radical excision for extensive disease.⁵ Reconstruction following surgical excision can be achieved by primary closure, secondary intention healing, and the use of skin flaps, depending on the size and location of the defect.⁶ The gluteal region is frequently involved in HS, and in advanced cases, excision often results in substantial defects that pose both functional and aesthetic challenges. In these situations, the utilization of perforator flaps provides a reliable and advantageous reconstructive option.

Case Presentation

A 48-year-old male patient presented with an 8-year history of HS, which had significantly exacerbated over the preced-ing 1.5 years. He had previously received combination anti-biotic therapy with rifampicin and clindamycin under the supervision of a dermatologist, without achieving clinical improvement.

Physical examination revealed extensive lesions involving the bilateral gluteal and sacral regions, characterized by sinus tracts, scattered abscesses, and a malodorous discharge (►Fig. 1). Following wide local excision, the resulting defect measured approximately 32 x 14 cm (►Fig. 2). Reconstruc-tion was performed using bilateral superior gluteal artery perforator (SGAP) flaps, elevated from the subfascial plane. The pedicles were meticulously freed in at least 2 cm from surrounding fascia, and the flaps were transposed to cover the defect without tension or pedicle torsion. Donor sites were closed primarily (►Fig. 3).

Fig. 1 - Preoperative photograph of the patient. Extensive hidrade-nitis suppurativa is present in the gluteal region.

Fig. 1 - Preoperative photograph of the patient. Extensive hidrade-nitis suppurativa is present in the gluteal region.

Fig. 2 - On the patient’s right side, a superior gluteal artery perforator flap was advanced and the right hemigluteal region was closed; on the left side, the flap was only elevated.

Fig. 2 - On the patient’s right side, a superior gluteal artery perforator flap was advanced and the right hemigluteal region was closed; on the left side, the flap was only elevated.

Fig. 3 - The extensive defects on the gluteal region are closed by transposing bilateral superior gluteal artery perforator flaps and the donor area is closed primarily.

Fig. 3 - The extensive defects on the gluteal region are closed by transposing bilateral superior gluteal artery perforator flaps and the donor area is closed primarily.

The postoperative course was uneventful, with no compli-cations such as wound dehiscence or venous congestion. Drains were removed on postoperative day 6, and the patient was subsequently discharged. At 5-year follow-up, the pa-tient demonstrated excellent functional and aesthetic out-comes, with no recurrence of hidradenitis suppurativa (►Fig. 4). The flaps remained fully viable, and the patient was able to perform all daily activities without limitation.

Fig. 4 - Five years postoperatively, the patient showed excellent aesthetic and functional results without recurrence.

Fig. 4 - Five years postoperatively, the patient showed excellent aesthetic and functional results without recurrence.

Discussion

Multiple surgical techniques have been described for the management of HS; however, no single approach has emerged as the definitive gold standard. According to Gierek et al., local flaps are considered the gold standard for the surgical management of HS; however, they are often inade-quate for covering extensive defects resulting from wide excision.⁷ Sugio et al. reported that skin grafts can provide superior coverage compared to flaps in some cases; however, they are prone to contracture, which may compromise both functional and esthetic outcomes.⁸ While primary closure remains the fastest and simplest method for defect coverage. Dietrich et al. demonstrated that perforator-based flaps, such as lateral thoracic artery perforator (LTAP) and thoracodorsal artery perforator (TDAP), can be used for axillary reconstruc-tion in patients with hidradenitis suppurativa without causing contracture, compromising range of motion, or resulting in laxity, while also achieving excellent aesthetic outcomes.⁹ According to Unal et al. (2011), secondary-intention healing and skin grafting in the gluteal region can prolong patients’ return to daily and social activities and are often time-consuming. Perforator flaps, by contrast, offer long pedicles and a wide rotational arc, making them highly suitable for reconstructing extensive gluteal defects.¹⁰ In the surgical management of HS, perforator flaps offer superior cosmetic outcomes, enables a short postoperative recovery time, and can be effectively utilized for the reconstruction of extensive defects, without causing contracture or compromising range of motion.^11,12 In our case, an extensive gluteal defect resulting from wide excision for HS was successfully recon-structed using bilateral superior gluteal artery perforator (SGAP) flaps, allowing the patient to return to social activi-ties early and achieving both excellent functional and cos-metic outcomes, thereby supporting the use of perforator flaps as a reliable option for large gluteal defects in similar cases.

Conclusion

Bilateral SGAP flaps provide a reliable and effective recon-structive option for extensive gluteal defects resulting from wide excision of hidradenitis suppurativa. In our case, the use of bilateral SGAP flaps enabled complete defect coverage, preservation of range of motion, avoidance of contracture, and excellent cosmetic outcomes. The patient was able to return to social activities early, demonstrating the functional and aes-thetic advantages of perforator flaps in managing large gluteal HS lesions. The present case supports the broader use of perforator flaps as a safe, versatile, and reproducible tech-nique for extensive gluteal reconstruction in HS.